21st Century Textbooks of Military Medicine - War Psychiatry: Combat Stress, Postcombat Reentry, Traumatic Brain Injury, PTSD, Prisoners of War, NBC Casualties (Emergency War Surgery Series)
U.S. Military, Department of Defense, U.S. Army, Borden Institute, Surgeon General
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Chapter 1
PSYCHIATRIC LESSONS OF WAR
FRANKLIN D. JONES, M.D., F.A.P.A.*
*Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and Neurology Consultant, Office of The Surgeon General, U.S. Army
INTRODUCTION
War, with its lesser elaborations such as competitive sports, has been an enduring aspect of human existence. Survival for the prehuman individual and the species was largely dependent on the evolution of physical attributes until fairly late in human development. The ability of prehumans and humans to organize into groups resulted in the supplanting of biological evolution with social evolution. Social evolution was so powerful an agency that while modern humans are less well developed physically than their human and prehuman ancestors, they are nevertheless more capable of survival. Social evolution has necessarily been accompanied by psychological evolution such that the two cannot be separated. In modern wars, beyond a minimal level of physical fitness and technical learning of how to fight, the soldier’s most important training is in social-psychological reaction patterns, particularly the handling of fear and aggression and the bonding with a group for accomplishing the military mission.
While wars differ along many dimensions ranging from ideology to technology, the human element remains the same. After millions of years of evolutionary molding, the human organism is reasonably well equipped physically to fight the solitary or group combat that our Stone-Age ancestors endured. This physical development alone, however, would never have allowed humans to achieve dominion over the natural world. This dominion resulted from the development of implements of combat and a social structure that facilitated cooperation in battle. Part of this social structure included the ability of protomen to band together on hunting expeditions as well as their ability to discover and then propagate the knowledge of how to make and use weapons. It is a striking observation that men through all periods of recorded history have fought ultimately as small groups consisting of from 2 to 20 or 30 persons. (1)
The same cultural evolution of groups that maximized warrior skills in the past, however, has increasingly prepared homo sapiens for peace rather than war. Individual psychology, reflecting family and cultural influences, often hinders rather than facilitates successful adaptation to combat. This can be seen, for example, in religious prohibitions against violence, which when internalized by any of a variety of processes, may even overcome near-instinctive behaviors for self-preservation. (2)
Erikson (3) gave a classic example of the interaction of the biological, interpersonal, and intrapsychic factors in the breakdown and later elaborations of symptoms in a World War II combat veteran.
Case Study: A Combat Crisis in a Marine.
The patient, a young teacher in his thirties, primarily suffered from severe headaches. History at a veterans’ clinic revealed that he was with a group of medical corpsmen who lay in pitch darkness on a South Pacific beachhead, pinned down by enemy fire, with little supporting fire from U.S. Navy ships. The group experienced mounting anger and fear; however, the patient seemed unaffected by the group anxiety. The patient did not drink, smoke, or even swear, and had chosen to be a medical corpsman because he could not bring himself to carry a gun.
During the night, he had only isolated memories of a dreamlike quality: the corpsmen were ordered to unload ammunition; the medical officer became angry, swearing abusively; someone thrust a submachine gun into the corpsman’s hands. By morning he was a patient sedated in the improvised hospital, with severe intestinal fever. At nightfall, the enemy attacked by air. The patient was immobilized and unable to care for the sick and wounded. He felt fear, and next day he was evacuated. At the rear area hospital he was initially calmer, but became upset and crawled under his sheets when the first meal was served. The metallic clanging of the mess kits sounded like salvos of incoming shots. He was plagued by severe headaches and when not suffering from them remained apprehensive, jumpy, easily startled. Although the fever which could have justified the initial headache was cured, his other symptoms persisted and he was evacuated home as a “war neurosis.”
Erikson found that the patient’s family had been in economic and moral decline. At age 14, the patient had left home after his mother, in a drunken rage, threatened him with a gun. He had secured the secret help of his principal, a fatherly man who protected and guided him, asking in exchange that he never drink, swear, indulge himself sexually, or touch a gun.
Erikson was able to separate out the biosociopsychological vulnerabilities that produced the breakdown. In the biological area were exhaustion and sleeplessness coupled with subliminal infection and fever. In the sociological area were the lowering of group morale and growth of group panic, immobilization under enemy fire, the inducement to give up in the hospital bed, and finally immediate evacuation creating a conflict between the desire to escape and the call to duty to care for his mates. In the psychological area were the loss of support for an idealized father substitute when the medical officer swore, and conflict over his identity as a noncombatant when a submachine gun was pressed on him, for “the gun had become the symbol of his family’s downfall and represented all … which he had chosen not to do.” (3) The subsequent headaches represented “the unconscious wish to continue to suffer in order to overcompensate psychologically for the weakness of having let others down; for many of these escapists were more loyal than they knew. Our conscientious man, too, felt ‘shot through the head’ by excruciating pain whenever he seemed definitely better.” (3)
Comment: This case illustrates not only the tripartite elements of combat breakdown but also the sequelae of improper treatment (evacuation) of such breakdown, in this case a chronic traumatic neurosis, which would currently be called post-traumatic stress disorder (PTSD). This chapter will, through historical analysis, show the importance of these elements in understanding combat breakdown and the importance of appropriate interventions.
Withstanding the Stress of Combat
The three groups of factors—biological (inherent propensities and physical attributes), interpersonal (cultural, social), and intrapsychic (individual psychological)—can affect positively or negatively the soldier’s ability to withstand the stresses of combat. Such stresses are multidimensional: injury; disease; physical and psychological fatigue; and fears of death, maiming, showing cowardice, and releasing aggressive and destructive tendencies. Recognition of these factors was slow to develop. Prior to the 20th century, most soldiers who broke down in combat were considered to be cowards or weaklings, an attitude that persists to this day in some settings. The result of this attitude was usually unfortunate for the soldier and the unit. The term “decimate,” for example, originally referred to the policy of killing every tenth soldier in a unit that had shown lack of fighting will in combat. When breakdown was recognized as medically legitimate before the 20th century, it was considered to be of organic causation, and terms such as “nostalgia” and “exhausted heart” were sometimes used. The recognition of biological/interpersonal/intrapsychic factors and their successful manipulation to prevent breakdown in combat or disasters and to facilitate recovery is the special province of military psychiatry. (4)
One example of a lesson not learned in the Russo-Japanese War is that providing a medical label for stress symptoms results in the development of such symptoms by other soldiers as an honorable way out of combat. (5)
PRE-20TH CENTURY CONCEPTIONS OF PSYCHIATRIC CASUALTIES
While combat stress breakdown and some of its causative factors were described in the epic accounts of early cultural mythology, not until the late 17th century were some of them given a particularly medical cognizance in the form of the diagnosis, nostalgia. Initially called “the Swiss disease” because of its prevalence among young Swiss uprooted from their villages and placed in mercenary armies, it was soon recognized as a more universal ailment. By the mid-18th century it was firmly established in the medical terminology with excellent clinical descriptions, as was discussed by Leopold Auenbrugger in his Inventum Novum of 1761:
When young men who are still growing are forced to enter military service and thus lose all hope of returning safe and sound to their beloved homeland, they become sad, taciturn, listless, solitary, musing, full of sighs and moans. Finally, they cease to pay attention and become indifferent to everything which the maintenance of life requires of them. This disease is called nostalgia. Neither medicaments, nor arguments, nor promises nor threats of punishment are able to produce any improvement. While all thought is directed toward ungratified desires, the body wastes away, with a dull sound (sonitus obscuras) on one side of the chest. [Some cases of nostalgia were undoubtedly linked with tuberculosis and other chest diseases. Such diseases were noted in the author’s descriptions of autopsy reports.—Au.] Some years ago this disease was rather common but now occurs very rarely since the wise arrangement was instituted of limiting the period of military service to a definite number of years. As a result the young men retain the hope of leaving military service after this period has elapsed, and of being able to return to their homes and enjoy their civic rights (6)
French physicians of the Napoleonic Era recognized numerous factors important in producing or preventing nostalgia; many of the same factors influence combat breakdown in the modern era. These physicians assessed the importance of conditions ranging from cultural (rural vs urban conscripts), and social (boredom vs rigorous activity and organized vs disorganized camp conditions), to environmental (clement vs inclement weather), and battle (victorious armies suffering few cases of nostalgia vs those experiencing reverses having many cases).
Baron Larrey, Napoleon’s Chief Surgeon, prescribed a course of treatment that, while ostensibly biologically oriented, reveals a keen awareness of social factors and is surprisingly close to modern handling of combat psychiatric casualties, both preventively and curatively:
[T]o prevent this sort of cerebral affection in soldiers who have lately joined their corps, it is necessary not to suffer those individuals who are predisposed to it more repose than is necessary to recruit their strength, exhausted during the day; to vary their occupations, and to turn their labours and recreations to their own advantage, as well as to that of society. Thus, after the accustomed military exercises, it is desirable that they should be subjected to regular hours, gymnastic amusements, and some mode of useful instruction. It is in this manner, especially, that mutual instruction, established among the troops of the line, is beneficial to the soldier and the state. Warlike music, during their repasts, or at their hours of recreation, will contribute much to elevate the spirits of the soldier, and to keep away those gloomy reflections which have been traced above. (6)
One could hardly ask for a better prescription to ensure physical bodily integrity and thus to produce a conviction of health, to give a sense of mastery of weapons and, as Larrey points out, especially to effect an integration into the unit through “mutual instruction, established among the troops of the line.” (6) This regimen prevents evacuation home (the treatment approach of earlier physicians) and minimizes any secondary gain from illness.
In parallel with their European colleagues, American physicians considered nostalgia to be a disorder associated with the military. No significant data are available concerning psychiatric casualties prior to the American Civil War, except that problems of alcoholism and desertion were not uncommon. Physicians during those times dealt almost entirely with surgical and infectious cases, leaving morale and discipline problems for commanders to handle. (7)
The Civil War, however, saw the first appearance of recognized nostalgic casualties in significant numbers. Approximately three cases of nostalgia per 1,000 troops per year were reported among Union soldiers, mainly among teenage conscripts. (8) Apparently lacking any knowledge of Larrey’s published insights, Civil War physicians urged screening as the primary method of preventing nostalgia. Surgeon General William A. Hammond in 1862 recommended that the minimum age of recruits be fixed at 20 years to screen out those prone to this condition; despite this effort, the rate did not change appreciably. (8) It was recognized, however, that group cohesion was important in preventing nostalgia and that the battle experience could forge these cohesive bonds. (9) Writing in a textbook of psychiatry 20 years after the Civil War, Hammond (10) recommended an army activity program similar to that of Larrey. He wrote: “The best means of preventing nostalgia is to provide occupation both for the mind and the body … soldiers placed in hospitals near their homes are always more liable to nostalgia than those who are inmates of hospitals situated in the midst of or in the vicinity of the army to which they belong.” (10) Hammond referred to Bauden’s account of the Crimean War in which similar principles were applied. He further stated that “in some cases it may be necessary for the military surgeon to send the nostalgic soldier to his home in order to save his life. This, however, should be done with all possible precautions to prevent his comrades becoming acquainted with the fact.” (10)
From 1861 to 1865 the Union Army officially recognized 2,600 cases of “insanity” and 5,200 cases of “nostalgia” requiring hospitalization at the Government Hospital of the Insane (now St. Elizabeths) in Washington, D.C. (7) Probably still in the realm of psychiatric casualties, in this same conflict there were 200,000 Union deserters and 160,000 cases of “constipation,” the latter reminiscent of the “precombat syndrome” (11)
Other psychiatric entities of the Civil War included malingering, which usually took the form of exaggerated trivial conditions or neurological symptoms, and the irritable and exhausted heart of DaCosta. (8) This latter condition was not recognized as a psychiatric entity and may well have included rheumatic and other heart disease. However, most cases diagnosed as exhausted heart were probably functional, secondary to anxiety. They may have resembled the neurocirculatory asthenia of World War I. (7)
In addition to innovations in treatment of surgical wounds and application of similar procedures pioneered by Florence Nightingale in the Crimean War a decade earlier, the major medical accomplishment during the Civil War was the establishment of the specialty of neurology by such pioneers as S. Weir Mitchell, W.W. Keen, G.R. Morehouse, and William A. Hammond. (8) The development of neurology laid the foundations for differentiating combat disorders with organic causes from those with psychological causes.
Following the Civil War, alcoholism, venereal diseases, and disciplinary infractions continued to be present in soldiers fighting the Indian Wars, the Spanish-American War, and the Philippine Insurrection, but these psychiatric problems in U.S. forces were not so labeled until World War I. Recognition of these and other aberrant behaviors as psychiatric problems first occurred during the Russo-Japanese War. (12)
20TH CENTURY COMBAT PSYCHIATRY
In the decade immediately preceding the outbreak of World War I, Russian physicians during the Russo-Japanese War (1904–1906) reportedly first utilized psychiatric specialists in the treatment of combat stress casualties both at the front and upon return to home territory. (12) This war also provided the first good description of war neurosis. Emphasis was placed on treatment of “insane” soldiers (an unfortunate term suggesting incurability), and no distinction was made between psychotic and neurotic soldiers. Although some psychiatric casualties were returned to combat, evacuation home, usually accompanied by psychiatric personnel, was the standard treatment. As this evacuation policy became known among the troops, the number of psychiatric patients increased 6- to 10-fold at some collecting points. (12) Nevertheless, such psychiatric casualties were not recognized as a significant source of personnel lost in battle until World War I.
Development of Principles
“Shell shock” was the popular label given to most World War I (1914–1918) neuropsychiatric casualties. (2) Jones, Belenky, and Marlowe (13) have discussed the impact of labeling in producing adverse outcomes in such casualties:
The interaction between label and belief and behavior was particularly striking in the consequences of the use of the term shell shock in World War I …. As a metaphor for the new shape of battle that characterized that war, it was particularly appropriate. In no previous conflict had men, pinned into place by the stasis of trench warfare, been subjected to artillery exchanges of such regularity, intensity and magnitude. The tactics of the day ensured that artillery shells and other explosive devices would be the primary cause of death, wounding, and stress. In a professional world in which most psychiatry was articulated to a neurological base, shell shock was initially seen as a species of actual shock to the central nervous system—a “commotional” syndrome that was the result of the effects of a blast pressure wave that was coupled to the body of the victim. Although the German, Oppenheim, had hypothesized a “molecular derangement” of brain cells as the pathologic agency, (14) a number of observations discredited this theory. Soldiers nowhere near an explosion developed “shell shock.” German prisoners of war exposed to shelling or bombing did not develop “shell shock” while their allied captors did. Soldiers exposed, or thinking themselves exposed, to toxic gases developed “shell shock.” Finally, Farrar, (15) after observing scores of Canadian soldiers with severe head injuries from shrapnel and gunshot wounds, noted that symptoms of psychosis or traumatic neurosis practically never occurred. He concluded “ … trench neuroses occur usually in unwounded soldiers.” (15)
In spite of the fact that British and French psychiatrists rapidly came to understand that the great majority of “shell-shocked” soldiers were the victims of transient stress-induced psychological disorders, the label and the beliefs and behaviors associated with it continued to exercise a major influence on the battlefield. While the clinicians dispensed with “shell-shock,” the troops did not. It became part of the self-diagnostic and self-labeling nomenclature of the soldier. (13)
British and French forces during World War I discovered the importance of proximity or forward treatment. The British had been evacuating neuropsychiatric casualties back to England and finding them most refractory to treatment. By 1917, when Salmon made his famous report on “shell shock” among British and French soldiers, one seventh of all discharges for disability from the British Army had been due to mental conditions; of 200,000 soldiers on the pension list of England, one fifth suffered from war neurosis. (2) However, within a few months of the onset of hostilities, British and French physicians had noted that patients with war neuroses improved more rapidly when treated in permanent hospitals near the front than at the base, better in casualty clearing stations than even at the advanced base hospitals, and better still when encouragement, rest, persuasion, and suggestion could be given in a combat organization itself. The importance of immediate treatment quickly became obvious when vicissitudes of combat prevented early treatment of war neuroses even in forward settings. Those who were left to their own devices due to a large influx of casualties were found more refractory to treatment and more likely to need further rearward evacuation. (2)
As an emissary of the U.S. Army Surgeon General, Thomas Salmon in 1917 observed and synthesized the British and French experience into a comprehensive program for the prevention and treatment of shell shock cases, which were renamed “war neuroses.” Salmon’s program, which involved placing psychiatrists in the divisions with forward hospitals to support them, was the first rational system of echelon psychiatry in U.S. military forces. American Expeditionary Forces (AEF) physicians fine-tuned this design based on their own experiences. (16) When fully conceptualized by Artiss, (17) three principles—proximity, immediacy, and expectancy—became the cornerstones of combat psychiatric casualty treatment. They referred to treating the combat psychiatric casualty in a safe place as close to the battle scene as possible (proximity), as soon as possible (immediacy), with simple treatment such as rest, food, and perhaps a warm shower (simplicity), and most importantly an explicit statement that he is not ill and will soon be rejoining his comrades (expectancy). Proximity and immediacy are important because the soldier’s time away from his unit weakens his bonds with it and allows time for consolidation of his rationalization of his symptoms. The patient’s rationalization may take many forms but basically consists of a single line of logic: “If I am not sick, then I am a coward who has abandoned his buddies. I cannot accept being a coward, therefore I am sick.” The psychiatrist offers an alternative hypothesis: “You are neither sick nor a coward. You are just tired and will recover when rested.”
Thomas Salmon inaugurated the principles of forward treatment of combat psychiatry casualties and was the Neuropsychiatry Consultant to the American Expeditionary Forces in World War I. He subsequently held many distinguished positions, including Presidency of the American Psychiatric Association, and is remembered for championing the mental health movement started by Clifford Beers.
Expectancy is the central principle from which the others derive. A soldier who is treated near his unit in space (proximity) and shortly after leaving it (immediacy) can expect to return to it. Distance in space or time decreases this expectancy. Similarly, the principle of simplicity derives from the concept of expectancy. The application of involved treatments such as narcosynthesis or electroshock treatment may only strengthen the soldier’s rationalization that he is ill physically or mentally. The occasional use of these more elaborate procedures in refractory cases actually reinforces the preeminent role of expectation; they convey the message: “Yes, you had a mild ailment; however, we have applied a powerful cure, and you are well.”
The role of expectancy can be seen in the labeling of these psychiatric casualties. Soldiers in World War I who were called “shell-shocked” indeed acted as though they had sustained a shock to the central nervous system. As recounted by Bailey, Williams, and Komora, “There were descriptions of cases with staring eyes, violent tremors, a look of terror, and blue, cold extremities. Some were deaf and some were dumb; others were blind or paralyzed.” (18) When it was realized that concussion was not the etiologic agent, the term “war neurosis” was used. This was hardly an improvement because even the lay public was aware that Freud had used William Cullen’s 1777 nonspecific term, “neurosis,” to describe chronic and sometimes severe mental illnesses. The soldier could readily grasp this medical diagnosis as proof of illness. This problem was remedied when medical personnel were instructed to tag such casualties as “N.Y.D. (nervous)” for “not yet diagnosed (nervous).” The term “N.Y.D. (nervous)” gave soldiers nothing definite to cling to and no suggestion had been made to help them in formulating their disorder into something that was generally recognized as incapacitating and requiring hospital treatment, thus honorably releasing them from combat duty. This left them open to the suggestion that they were only tired and a little nervous and with a short rest would be fit for duty. Eventually, many of these cases began to be referred to simply as “exhaustion,” then, with the rediscovery of the principles during World War II, as “combat exhaustion.” Finally, during World War II, the term “combat fatigue” came to be preferred in that it conveyed more exactly the expectation desired. (19)
Another finding of World War I was the “contagiousness” of medical disorders that allow honorable escape from combat. This occurs particularly in situations of ambiguity when such escape behavior can become an “evacuation syndrome,” as described by Belenky and Jones:
An evacuation syndrome develops in combat or in field training exercises when through accident or ignorance an evacuation route, usually through medical channels, opens to the rear for soldiers displaying a certain constellation of symptoms and signs…. In the First World War, lethal gases were used in combat. In one battle, an incident occurred in which soldiers from a certain division came to their medical aid stations in large numbers complaining of being gassed. This division had taken heavy casualties, but now was involved in a desultory holding action, with no particular aim or object. The soldiers in the division had been expecting to be relieved following the previous heavy fighting and when they had not been, morale had declined precipitously. During the current action, there was some gas shelling, but not of sufficient intensity to produce any serious casualties. Nevertheless, soldiers usually in groups of comrades were coming to their battalion aid stations complaining of cardiorespiratory symptoms. The medical personnel seeing these men evacuated them to the rear. An initial trickle of soldiers turned into a flood, and very soon this inappropriate evacuation of men—for symptoms only—turned into a significant source of manpower loss. Once the line commanders became aware of the magnitude of the ongoing loss they intervened and sought consultation from the division psychiatrist. The psychiatrist reorganized the system of evacuation by treating the soldiers coming to the aid station with a complaint of gas exposure and cardiorespiratory symptoms as psychiatric casualties. He gave them a brief rest, a warm drink, and a change of clothes, and rapidly returned them to their unit. The flow of men with cardiorespiratory complaints slowed and finally stopped. Overall the incident lasted over a week before it was finally terminated. (20) Similarly, during the Vietnam conflict, Jones reported an “epidemic” of sleepwalking, which is described in Chapter 2, Traditional Warfare Combat Stress Casualties]
Following World War I, the principles of forward treatment were gradually lost to the U.S. military. The psychoanalytic notion that the origin of psychiatric disorders could be traced to childhood trauma prevailed. A natural consequence of this theory was that evidence of such trauma could be detected, and such potential casualties screened out. The Spanish Civil War revealed an interesting admixture of this faith in screening along with a pragmatic application of forward treatment of combat stress casualties.
Application of Principles
The Spanish Civil War (1936–1939) was a struggle between a monarchist-military faction supported with money, equipment, and volunteers by Germany and Italy and a republican-socialist faction supported by France, the United States, and the Soviet Union. Much of the combat psychiatry learned in this war was not available until after World War II because those who learned the proper handling of psychiatric casualties were on the losing side and were scattered. Mira, the psychiatrist who set up the mental health program for the Spanish Republican Army, gave the Thomas W. Salmon Memorial Lecture in 1942 and later expanded it into a book. His work was not published until late in World War II, by which time U.S. forces had relearned the lessons of World War I. Mira made two main contributions to the literature of combat psychiatry: (1) the revalidation of forward treatment for psychiatric casualties, and (2) the value of psychiatric screening. The latter point will be addressed first.
Mira (21) described a written psychiatric questionnaire to be filled out by potential recruits for the Spanish Republican Army. The 17 questions, when skillfully interpreted, allowed the physician to assess motivation, intelligence, and, it was believed, the probability that men were “likely to suffer from war neurosis.” After demographic questions, the following were then asked: “Do you ever faint?” “Do you suffer from dizziness?” “How often do you have sexual relations?” “How often would you like to have a 7-day leave if it were possible? Where and how would you spend the time?” (21)
According to Mira,
Broadly speaking, the cases of mental and neurotic disorders occurring subsequently in the group of approximately twenty thousand troops selected in this way were three times less frequent than among those not given any such examination. This suggests that considerable value would be derived from the adoption of this or similar methods of selection and group testing at the recruiting centers. (21)
Although Mira attributed the very low rate of psychiatric casualties to screening, it seems more likely, based on U.S. experience in World War II and Vietnam, that the policy of forward treatment, including “forward evacuation,” was far more critical than screening in accounting for the low figures. The forward treatment program reported by Mira seems to have worked well.
Late in the war (July 1938), Mira organized the various psychiatric services that had developed during the war into a coordinated program of 5 centers with 32 psychiatrists. (21) Not all of the rear area military psychiatric casualties were evacuated to the central psychiatric clinic (in the civilian zone) but some were sent toward the forward emergency psychiatric center of the corresponding battle sector. In Mira’s words, “They were surprised that instead of going backward they were moved ahead when they complained of mental disorder! The purpose was to avoid the encouragement of malingering or the exaggeration of nervous symptoms as a means of escape from the hardships of military life.” (21) Psychiatric casualties in the front lines were “not to be put to bed but treated boldly by suggestive measures and directly transferred … where much gymnastic and kinetic exercise was the basis of their readjustment.” (21) The average percentage of recovery of psychiatric casualties from the front centers was reported to be 93.6%, and the total percentage of men temporarily discharged because of war neurosis was not greater than 1.5%. (21) Subsequent experience with similar procedures suggests that the high recovery and low discharge rates were primarily attributable to forward evacuations. The Israelis in the 1982 Lebanon War also successfully utilized “forward evacuation” and a stringent physical fitness program for psychiatric casualties. (22)
Unfortunately, the forward treatment methods used in the Spanish Civil War were unknown by U.S. physicians at the inception of World War II and had to be painfully relearned. Furthermore, American recruiters shared Mira’s view of the efficacy of psychiatric screening, resulting in the rejection of hundreds of thousands of potentially effective soldiers during World War II. World War II studies suggest that beyond minimal screening to eliminate severe mental disorders such as schizophrenia or brain deficits, mass screening is inefficient. (23)
Rediscovery and Extensive Application of Principles
The United States became involved in World War II in 1941, 2 years after its outbreak in Europe. At the outset, American medical personnel were unprepared to carry out the program of forward psychiatry that had been devised by World War I psychiatrists. No psychiatrists were assigned to combat divisions and no provisions for special psychiatric treatment units at the field army level or communications zone had been made. (24) American planners under the guidance of Harry Stack Sullivan had believed that potential psychiatric casualties could be screened out prior to induction. (7)
To minimize these casualties, physicians at the outset of hostilities did not select draft registrants who had any significant history of psychiatric disturbance, especially those with anxiety symptoms. Furthermore, soldiers showing symptoms after induction were expeditiously discharged. In effect, production of psychiatric symptoms as an honorable way of avoiding induction produced a massive loss of manpower reminiscent of an evacuation syndrome.
Although about 1,600,000 registrants were classified as unfit for induction during World War II because of mental disease or educational deficiency (a disqualification rate about 7.6 times as high as in World War I), separation rates for psychiatric disorders in World War II were 2.4 times as high as in World War I. (24) Not only was screening ineffective in preventing breakdown, but also the liberal separation policy for those presenting with neurotic symptoms threatened the war effort. For instance, in September 1943 more soldiers were being eliminated from the U.S. Army than accessed; most of those separated were for psychoneurosis (35.6/1,000/y). (24)
Studies attempting to find predisposition to psychiatric breakdown in combat have revealed more similarities between psychiatric casualties and their fellow soldiers than differences. For example, in a comparison of the combat records of 100 men who suffered psychiatric breakdowns requiring evacuation to a U.S. Army hospital in the United States and an equivalent group of 100 surgical casualties, Pratt (25) found no significant difference in numbers of awards for bravery. Glass remarked, “Out of these experiences came an awareness that social and situational determinants of behavior were more important than the assets and liabilities of individuals involved in coping with wartime stress and strain;” (19) The reliance on screening to prevent psychiatric casualties was recognized as a failure when large numbers of these casualties occurred during fighting in North Africa. Because no provision for treatment had been made, they were shipped to distant centers from which they never returned to combat.
World War I-style forward treatment was relearned during two battles of the Tunisian Campaign in March and April 1943. (26) Captain Fred Hanson, a U.S. Army psychiatrist from Canada who may have been familiar with the Salmon Lectures, avoided evacuation and returned more than 70% of 494 neuropsychiatric patients to combat after 48 hours of treatment, which basically consisted of resting the soldier and indicating to him that he would soon rejoin his unit. (26) On April 26, 1943, in response to the recommendations of his surgeon, Colonel Long, and psychiatrists, Captain Hanson and Major Tureen, General Omar Bradley issued a directive that established a holding period of 7 days for psychiatric patients and further prescribed the term “exhaustion” as the initial diagnosis for all combat psychiatric cases. (26) The word exhaustion was chosen because it conveyed the least implication of mental disturbance and came closest to describing how the patients really felt. The World War I principles had been rediscovered! (26)
Discovery of Mediating Principles
In addition to rediscovering the principles of treatment applied so effectively in World War I, and the ineffectiveness of large-scale screening, World War II psychiatrists learned about the epidemiology of combat stress casualties (direct relationship to intensity of combat, modified by physical and morale factors) and the importance of unit cohesion both in preventing breakdown and in enhancing combat effectiveness. During the war, prospective studies conducted by Stouffer and colleagues (27) conclusively showed that units with good morale and leadership had fewer combat stress casualties than those without these attributes when variables such as combat intensity were comparable.
The dependent relationship of combat stress casualties to combat intensity, as measured by rates of wounded in action, can be seen in Beebe and De Bakey. (28) The absence of such a relationship in the Southwest Pacific Theater was explained by Beebe and De Bakey as a collection problem; however, this may be a phenomenon of sporadic combat. In such warfare, neuropsychiatric casualties take the form of venereal disease, alcohol and drug abuse, and disciplinary problems. This phenomenon, which has been detailed by Jones (29) for subsequent wars, will be discussed later.
Another finding during World War II was the chronology of breakdown in combat. It had long been recognized that inexperienced troops were more likely to become stress casualties. Green troops have usually accounted for over three fourths of stress casualties; however, with increasing exposure to combat after 1 or 2 combat months, an increasing rate of casualty generation also occurs. Sobel (30) described the anxious, depressed soldier who broke down after having lived through months of seeing friends killed, as “the old sergeant syndrome.” Today, it would probably be called chronic post-traumatic stress disorder. Swank and Marchand (31) discussed the relationship of combat exposure and combat effectiveness. Thus, the theory of ultimate vulnerability was promulgated and usually expressed as “everyone has his breaking point.” Hanson and Ranson (32) found that while a soldier who broke down after his unit experienced 4 to 5.5 months of combat exposure could be returned to full combat duty in 70% to 89% of cases, those exposed over 1 year returned in only 32% to 36% of cases.
Beebe and Appel (33) analyzed the World War II combat attrition of a cohort of 1,000 soldiers from the European Theater of Operations (ETO). They found that the breaking point of the average rifleman in the Mediterranean Theater of Operations (MTO) was 88 days of company combat, that is, days in which the company sustained at least one casualty. A company combat day averaged 7.8 calendar days in the MTO and 3.6 calendar days in the ETO. They found that due to varying causes of attrition in both theaters, including death, wounding, and transfers, by company combat day 50, nine of 10 “original” soldiers had departed. In their projections, Beebe and Appel found that if only psychiatric casualties occurred, there would be a 90% depletion by company combat day 210; however, due to other causes of attrition (transfer, death, wounding, illness), the unit would be virtually depleted by company combat day 80 or 90, approximately the breaking point of the median man. (33)
Noy (34) reviewed the work of Beebe and Appel and found that soldiers who departed as psychiatric casualties had actually stayed longer in combat duties than medical and disciplinary cases and that their breakdowns were more related to exposure to battle trauma than were medical and disciplinary cases.
From studies of cumulative stress such as these as well as observations of the efficacy of a “point system” (so many points of credit toward rotation from combat per unit of time in combat or so many combat missions of aircrews) used during World War II, the value of periodic rest from combat and of rotation came to be understood. (19)
The final and perhaps most important lesson of World War II was the importance of group cohesion not only in preventing breakdown, (19) but also in producing effectiveness in combat. This latter point is demonstrated by Marshall’s (35) account of soldiers parachuted into Normandy. The imprecision of this operation resulted in some units being composed of soldiers who were strangers to each other and others with varying numbers who had trained together. Uniformly, those units of strangers were completely ineffective. In Men Against Fire, Marshall (36) had also observed that only a small percentage (about 15%) of soldiers actually fired their rifles at the enemy during World War II but that in group firing activities, among members of crew-served weapons teams such as machine guns, the percentage was much higher.
This element of group cohesion has already been alluded to in terms of morale and leadership. Marshall again probably made the point best in reviewing his experiences in World War I, World War II, Korea, and various Arab-Israeli wars:
When fire sweeps the field, be it in Sinai, Pork Chop Hill or along the Normandy coast, nothing keeps a man from running except a sense of honor, of bound obligation to people right around him, of fear of failure in their sight which might eternally disgrace him. (37)
Cohesion is so important in both prevention and treatment of psychiatric casualties that Matthew D. Parrish, an eminent psychiatrist who served in combat aircrews during World War II and as U.S. Army Neuropsychiatry Consultant in Vietnam, has suggested it as another principle of forward treatment. (38) Parrish observed that combat fatigue patients who had regular visits from their units in which they were welcomed to return, were far more likely to do so. He suggested that this preventive and curative principle be termed “membership.”
In the words of Parrish,
[T]he principles of proximity, immediacy, simplicity, expectancy … seem to imply that the medics are trying to get the individual so strong within his own separate self that he will be an effective soldier. Thus we would have a newly pre-combat person with a strong character and therefore could be predicted to perform well. There is no … mention of the principle [of] … the maintenance of his bonded membership in his particular crew, squad or team (at least no larger than company). This bonding maintained, he never faces combat alone. In Vietnam, when possible, the entire such primary group would visit the casualty, keep him alive to the life of the group and show him the other members’ need for him. Often an “ambassador” would visit and leave a sign on the casualty’s bed announcing that he was a proud member of his unit. (This sort of thing was effective for some medical and surgical casualties too, who could easily have developed the evacuation syndrome.) What did we call this 5th principle? All I can think of is membership. Of course, like everything else in psychiatry, it is ultimately a command responsibility—yet its effectiveness is in the hands of team leaders and the troops themselves (38)
In summary, World War II taught combat psychiatrists that psychiatric casualties are an inevitable consequence of life-threatening hostilities, that they cannot be efficiently screened out ahead of time, that their numbers depend on individual, unit, and combat environmental factors, and that appropriate interventions can return the majority to combat duty.
Validation and Limitations of Principles
Just as in the initial battles of World War II, provisions had not been made for psychiatric casualties in the early months of the Korean conflict (1950–1953). As a result they were evacuated from the combat zone. Due largely to the efforts of Colonel Albert J. Glass, a veteran of World War II, who was assigned as Theater Neuropsychiatry Consultant, the U.S. combat psychiatric treatment program was soon in effect and generally functioning well. (39)
Albert Julius Glass taught and popularized the principles of forward treatment throughout his life. He was a division psychiatrist in World War II, where his experiences shaped his views of appropriate care of stress casualties. In the Korean conflict, as Theater Neuropsychiatry Consultant, he instituted policies that maximized the effectiveness of treatment of psychiatric casualties. Subsequently, he applied these principles to the garrison military as Psychiatry and Neurology Consultant to the U.S. Army Surgeon General, resulting in closure of five of the six U.S. Army prisons. After his retirement from the military, he edited Neuropsychiatry in World War II, the two-volume official history of neuropsychiatry in the Zone of the Interior (Vol 1) and the Overseas Theaters (Vol 2).
Since only 5 years had elapsed, the lessons of World War II were still well known and the principles learned during that war were applied appropriately. Combat stress casualties were treated forward, usually by battalion surgeons and sometimes by an experienced aidman or even the soldiers’ “buddies,” and returned to duty. Psychiatric casualties accounted for only about 5% of medical out-of-country evacuations, and some of these (treated in Japan) were returned to the combat zone. (39) To prevent psychiatric casualties, a rotation system was in effect (9 months in combat or 13 months in support units). (39) In addition, attempts were made to rest individuals (“R and R” or rest and recreation) and, if tactically possible, whole units. Marshall (40) warned of the dangers to unit cohesion of rotating individuals, but this lesson was not to be learned until the Vietnam conflict.
These procedures appear to have been quite effective with two possible exceptions. One was the development of frostbite as an evacuation syndrome. This condition, which was the first psychiatric condition described in the British literature during World War I, (41) was almost completely preventable, yet accounted for significant numbers of “ineffectives.”
The other problem was an unrecognized portent of the psychiatric problems of rear-area support troops. As the war progressed, U.S. support troops increased in number until they greatly outnumbered combat troops. These support troops were seldom in life-endangering situations. Their psychological stresses were related more to separation from home and friends, social and sometimes physical deprivations, and boredom. Paradoxically, support troops who may have avoided the stress of combat, according to a combat veteran and military historian, were deprived of the enhancement of self-esteem provided by such exposure. (42) To an extent the situation resembled that of the nostalgic soldiers of prior centuries. In these circumstances the soldier sought relief in alcohol abuse (and, in coastal areas, in drug abuse) (43) and sexual stimulation. These often resulted in disciplinary infractions. Except for attempts to prevent venereal diseases, these problems were scarcely noticed at the time, a lesson not learned.
The Korean conflict revealed that the appropriate use of the principles of combat psychiatry could result in the return to battle of up to 90% of combat psychiatric casualties; however, there was a failure to recognize the types of casualties that can occur among rear-echelon soldiers. (11) These “garrison casualties” later became the predominant psychiatric casualties of the Vietnam conflict. (11) Vietnam and the Arab-Israeli wars revealed limitations to the traditional principles of combat psychiatry.
TABLE 1-2
SELECTED CAUSES OF ADMISSION TO HOSPITAL AND QUARTERS AMONG ACTIVE DUTY U.S. ARMY PERSONNEL IN VIETNAM, 1965–1970
Cause / Rate Expressed as Number of Admissions (per 1,000 Average Strength)
Cause / 1965 / 1966 / 1967 / 1968 / 1969 / 1970
Wounded in Action / 61.6 / 74.8 / 84.1 / 120.4 / 87.6 / 52.9
Neuropsychiatric Conditions / 11.7 / 12.3 / 10.5 / 13.3 / 15.8 / 25.1
Viral Hepatitis / 5.7 / 4.0 / 7.0 / 8.6 / 6.4 / 7.2
Venereal Disease (includes CRO*) / 277.4 / 281.5 / 240.5 / 195.8 / 199.5 / 222.9
Venereal Disease (excludes CRO*) / 3.6 / 3.8 / 2.6 / 2.2 /1.0 / 1.4
*CRO: Carded for record only, ie, not hospitalized Adapted from Neel S. Vietnam Studies: Medical Support of the US Army in Vietnam, 1965–1970. Washington, DC: US Department of the Army; 1973: 36.
America’s longest conflict, Vietnam (1961–1975), can best be viewed from a psychiatric perspective as encompassing three phases: (1) an advisory period with few combatants and almost no psychiatric casualties; (2) a build-up period with large numbers of combatants but few psychiatric casualties; and (3) a withdrawal period in which relatively large numbers of psychiatric casualties took forms other than traditional combat fatigue symptomatology.
During the initial phases of the build-up in Vietnam, the psychiatric program was fully in place, with abundant mental health resources and psychiatrists fairly conversant with the principles of combat psychiatry. Combat stress casualties, however, failed to materialize. Throughout the entire conflict, even with a liberal definition of combat fatigue, less than 5% (and nearer to 2%) of casualties were placed in this category. (11)
The Vietnam conflict produced a number of paradoxes in terms of the traditional understanding of psychiatric casualties. Most spectacular was the low rate of identified psychiatric casualties generally and, in particular, the relative absence of the transient anxiety states currently termed combat fatigue or combat reaction. Table 1-2, taken from statistics compiled by Neel, (44) reveals that the Vietnam conflict was unusual in that the psychiatric casualty rate did not vary directly with the wounded-in-action rate. Despite the decline of the wounded-in-action rate by more than half in 1970 compared with the high in 1968, the neuropsychiatric casualty rate in 1970 was almost double the 1968 rate. In other words, wounded-in-action and neuropsychiatric casualty rates showed an inverse relationship that was unique to the Vietnam conflict until the 1982 Lebanon War.
This was contrary to prior experience and expectations. For example, Datel, (45) in reviewing neuropsychiatric rates since 1915, showed that in the U.S. Army the rates had previously peaked coincidentally with combat intensity (1918, 1943, and 1951) but in the Vietnam conflict they peaked after the war was over (1973).
In one study of combat psychiatric casualties in Vietnam (46) during the first 6 months of 1966, less than 5% of cases were labeled “combat exhaustion.” Most cases presented with behavioral or somatic complaints.
This initially (1965–1967) low incidence of neuropsychiatric cases in Vietnam was posited by Jones (47) to reflect the low incidence of combat fatigue in Vietnam compared to other wars. This low incidence of combat fatigue was in turn attributed to the 12-month rotation policy, the absence of heavy and prolonged artillery barrages, and the use of seasoned and motivated troops. Because the rate of psychiatric cases did not increase with increased utilization of drafted troops in 1966 as compared to 1965, the latter consideration seems less important. Other explanations of the low incidence of psychiatric cases included thorough training of troops, troops’ confidence in their weapons and means of mobility, helicopter evacuation of wounded, early treatment of psychiatric casualties in an atmosphere of strong expectation of rapid return to duty, and a type of combat that consisted largely of brief skirmishes followed by rests in a secure base camp. Fatigue and anxiety did not have a chance to build up.
Huffman (48) suggested that a factor in the low incidence of psychiatric cases was the effectiveness of stateside psychiatric screening of troops being sent to Vietnam. This possibly affected in a sporadic way the initial deployment of troops because some company level commanders did attempt to eliminate “oddballs” from their units in anticipation of future noneffectiveness; however, no organized screening program beyond basic combat and advanced individual training was in effect.
In an interesting sociological and psychodynamic analysis of 1,200 U.S. Marine Corps and U.S. Navy personnel serving in the Vietnam combat zone, Renner (49) suggested that the true picture was not one of diminished psychiatric casualties but rather of hidden casualties manifested in various character and behavior disorders. These character and behavior disorders were “hidden” in the sense that they did not present with classical fatigue or anxiety symptoms but rather with substance abuse and disciplinary infractions. Renner developed evidence supporting an explanation of character and behavior disorders based on a general alienation of the soldier from the goals of the military unit. He contrasted support units with combat units, noting that the former faced less external danger, allowing greater expression of the basic alienation that he regarded as present among virtually all U.S. troops in Vietnam. He attributed this alienation to the lack of group cohesiveness largely resulting from the policy of rotating individuals and disillusionment with the war after 12 months. The result was that the prime motivative behaviors became personal survival, revenge for the deaths of friends, and enjoyment of unleashing aggression. These in turn produced not only disordered behavior reflected in increased character and behavior disorder rates but also feelings of guilt and depression. Alienation from the unit and the U.S. Army led to the formation of regressive alternative groups based on race, alcohol or drug consumption, delinquent and hedonistic behavior, and countercultural life styles.
A second paradox in the Vietnam conflict was the development of greatly increased rates of psychosis in U.S. Army troops (11). Datel (45) showed that this was a worldwide phenomenon of all active duty personnel, but especially of U.S. Army troops. Like the total neuropsychiatric incidence rate previously mentioned, the psychosis rate also peaked after active combat. Previous experience had shown only minor increases in the psychosis rate during wartime. In both combat and noncombat situations the psychosis rate had remained stable at approximately two or three per 1,000 troops per year. (7)
Hayes (50) suggested two hypotheses to explain the increase in psychoses. One was the increased precipitation of schizophrenia and other psychotic reactions in predisposed persons by their use of psychoactive drugs. The other was the tendency of recently trained psychiatrists to classify borderline syndromes as latent schizophrenia, while more experienced psychiatrists would have chosen a different nosological category (presumably character and behavior disorders).
Jones and Johnson (11) suggested that the doubling of the psychosis rate in the U.S. Army Vietnam (USARV) troops in 1969 was due not to drug precipitation of schizophrenia or styles of diagnosis per se but rather due to the influence of drugs in confusing the diagnosis. Holloway (51) showed that large scale abuse of drugs other than marijuana and alcohol began about 1968. Approximately 5% of departing soldiers were excreting detectable heroin products in the summer of 1971; however, this fell to about 3% when the screening became publicized. Soldiers frequently took potent hallucinogens as well as marijuana and heroin. Jones and Johnson (11) showed that out-of-country evacuations were essentially reserved for psychotics until the beginning of 1971 but with the advent of emphasis on drug abuse identification and rehabilitation, often by detoxification and evacuation to stateside rehabilitation programs, an alternative diagnosis was available. Finding a new diagnostic category for soldiers who just did not belong in a combat zone, namely, drug dependence, the evacuating psychiatrists stopped using the schizophrenia label. This is reflected in the decline in psychosis back to approximately two per 1,000 troops per year. (11) Also, fluctuation began to increase due to the smaller samples.
In other overseas areas the U.S. Army policy of not evacuating persons with character and behavior problems, including drug dependence, still held; therefore, the psychiatrist seeing a patient who did not belong overseas might label him with a psychosis, especially if the patient described perceptual distortions and unusual experiences. Such a psychiatrist might be applying a broad categorization of schizophrenia as Hayes suggests. Because U.S. Air Force and U.S. Navy psychiatrists have generally had more latitude in being permitted to evacuate patients with character and behavior problems than have U.S. Army psychiatrists, one would expect their rates of psychosis to be lower, and, in fact, they were. This may explain the discrepancy between Datel’s worldwide psychosis rate with diagnoses by U.S. Navy, U.S. Air Force, and U.S. Army psychiatrists and Jones and Johnson’s Vietnam psychosis rate with diagnoses by U.S. Army psychiatrists only.
Vietnam revealed the limits of World War II-type psychiatric treatment policy in a low-intensity, prolonged, unpopular conflict. Such conflicts, if they cannot be avoided, must be approached with primary prevention as the focus. Career soldiers with strong unit cohesion will not endanger themselves, their fellows, or their careers by abusing alcohol or drugs. When casualties do occur, the Larrey treatment for nostalgia, mentioned earlier, can be used as a model. (6)
Since World War II (as, indeed, long before World War II), the Middle East has experienced essentially continual conflict of every conceivable nature. Exhibit 1-3 illustrates the variety of these conflicts, ranging from state-sponsored terrorism, in which countries fight indirectly and often by proxy, through low-intensity and guerrilla warfare to high-intensity and even chemical warfare. The significance of terrorist activities should not be minimized. In 1983, a single terrorist suicide attack killed 241 U.S. Marines on a peace-keeping mission in Beirut, producing nearly as many deaths as the Spanish-American War. (52, 53)
EXHIBIT 1-3
POST-WORLD WAR II MIDDLE-EAST CONFLICTS
1948: Israel fought the Arab League in a civil war which became Israel’s war of independence
1956: Egypt fought the tripartite powers (France, Great Britain, and Israel) when they attempted to prevent Egypt from asserting sovereignty over the Suez Canal; ie, repulsion of former colonial powers
1962: Egypt fought against the Royalists in the Yemen Civil War, somewhat similar to the U.S. involvement in Vietnam, a guerrilla war
1967: Israel launched a preemptive surprise attack on Egypt and her allies, a conventional medium-intensity war but of brief duration
1968–1970: Arab-Israeli War of Attrition, a war with a static front and primarily indirect fire, thus having some similarity to World War I
1973: Egypt launched a surprise attack on the Israelis in what became an example of high-intensity, high-technology, continuous combat
1982: Israel bombed a nuclear reactor in Iraq, thus even a “nuclear” war (but radioactive material had not yet been acquired by Iraq)
1982: Israel attacked Palestine Liberation Organization forces in Lebanon, a state within a state. This was a war fought in an area of high-density civilian population, with besieged cities reminiscent of the latter phases of World War II
1982–1987: Iraq-Iran War, primarily a conventional war but with the use of chemical agents
1989–1990: Intifada in Israeli-occupied Palestinian territories. Urban guerrilla war carried out largely by adolescents repressed by Israeli army
1991: Persian Gulf War; U.S.-led coalition war against Iraq was primarily an uncontested aerial attack for 5 weeks followed by a 4-day ground assault using conventional weapons
1991: Iraqi war between the established government and Shiite and Kurdish minorities
Adapted from Jones FD. Lessons of the Middle Eastern Wars. Originally presented at Grand Rounds, Psychiatry Department, Walter Reed Army Medical Center; March 15, 1984 with subsequent updates; Washington, DC.
The periodic wars between Israel and its Arab neighbors have served as a human factors laboratory as well as a testing ground for technological. developments in weapons systems (see Exhibit 1-3). In 1967, Egyptian ground troops, surprised by Israel with its air superiority, had a feeling of helplessness that resulted in large numbers of psychiatric casualties. Having been surprised by Israel in the 1967 Six Day War, the Arabs had learned the effectiveness of surprise so well that Israel was almost defeated before it could organize its defenses against the sudden 1973 Arab attack. From the perspective of psychiatric breakdown, the 1973 Yom Kippur War is most instructive. For the first time Israel suffered significant combat stress casualties, initially reported as 10% of total casualties, but later estimated to be from 30% to 50%. (54) The 10% rate was artificially low because casualties treated at forward medical facilities and returned to duty were not counted; only those disabled longer than 4 days and sent to rear hospitals were counted. In addition, soldiers who were psychiatrically disabled but also had light wounds were not counted as psychiatric casualties but as wounded in action. Finally, psychiatric casualties occurring after 26 October 1973 (2 days after the cease-fire) were not counted.